Acar, Emine Müge

Kemeriz, Funda

Kilitci, Asuman

Tad, Murat

Clinical Case Reports

Aksaray University Institutional Repository

CASE REPORTHemosiderotic dermatofibroma mimicking melanoma in a12-year-old boy: a case reportEmine M€uge Acar1 , Murat Tad2, Asuman Kilitci2 & Funda Kemeriz31Department of Dermatology, Kırsehir Ahi Evran University Training and Research Hospital, Kırsehir 40200, Turkey2Department of Pathology, Kırsehir Ahi Evran University Training and Research Hospital, Kırsehir 40200, Turkey3Department of Dermatology, Aksaray University Training and Research Hospital, Aksaray 68200, TurkeyCorrespondenceEmine M€uge Acar, Kırsehir Ahi EvranUniversity Training and Research Hospital,Kervansaray district, 2019 Street, No: 1,Kırsehir, Turkey. Tel: +90 386 213 45 15;Fax: +90 386 213 33 98;E-mail: drmugeacar@gmail.comFunding InformationNo sources of funding were declared for thisstudy.Received: 5 December 2017; Revised: 7March 2018; Accepted: 8 March 2018Clinical Case Reports 2018; 6(6): 1006–1009doi: 10.1002/ccr3.1508Key Clinical MessageWe report a case of hemosiderotic dermatofibroma presenting as a brown-black-colored nodule with peripheral extensions, which mimics melanoma.Histopathology showed completely benign features with no atypia or mitosis.Nodular extensions of childhood dermatofibromas may be related to thegrowth of the child not necessarily pointing to a malignant process.KeywordsChild, dermoscopy, hemosiderotic dermatofibroma, melanoma.IntroductionDermatofibroma (DF) is a common benign fibrohistio-cytic tumor of the skin and has a slight female prepon-derance [1]. DF is characterized by solitary or multiple,firm, red-brown-colored dermal nodules with a predilec-tion for the lower extremities [2, 3]. DF most commonlyaffects young adults and can also be seen in pediatric agegroup [1, 3, 4]. The diagnosis of the classical type of der-matofibroma is predominantly based on the clinical anddermoscopic features, but atypical variants can pose adiagnostic challenge [1, 5, 6]. Hemosiderotic DF is anatypical and rare variant of DF that can be clinically anddermoscopically indistinguishable from melanoma [3].Here, we report a case of hemosiderotic DF, which clini-cally mimics melanoma, on the right knee of a 12-year-old boy.Case ReportA 12-year-old boy presented to our clinic with a firm,nodular mass on the medial aspect of the right knee witha history of about 1 year. The lesion was not pruritic orpainful, but mild tenderness was present. The patient sta-ted that the size of the nodule had gradually increasedover the last 3 months. Physical examination revealed adark brown-black nodule, measuring about 1 9 1 cm,with two small nodular extensions from the periphery(Figs 1 and 2). There was neither ulceration nor crusting,and the dimple sign was negative. The patient gave nohistory of skin disease or other systemic disorders.Dermoscopy revealed focally localized blue-red pigmen-tation areas on a white structureless background andpinkish red area at the periphery surrounded by brownpigmentation (Fig. 3). The lesion was excised with 5-mmclear margins with preliminary diagnosis of nodular mela-noma. On histopathological examination, a benign tumorcomposed of interlacing fascicles of spindle cells in thedermis with a storiform pattern and containing hemosi-derin deposits was seen (Fig. 4A and B). Intracellular andextracellular hemosiderin deposits were demonstratedwith the Prussian blue stain (Fig. 4C and D). Atypia andmitosis were not present. Factor XIIIa (FXIIIa) stainingwas positive, and CD34, S-100, smooth muscle actin1006 ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.This is an open access article under the terms of the Creative Commons Attribution License, which permits use,distribution and reproduction in any medium, provided the original work is properly cited.(SMA), and cytokeratin (AEI/AEI3) stains were negative.The diagnosis of hemosiderotic DF was established withthese histopathological findings. There was no recurrenceduring 1 year of follow- up.DiscussionDermatofibroma is a benign dermal fibrohistiocytic tumorwith a slight female predominance [1]. It is generally seenin young adults and is less often reported in children [3].Most DFs present in the lower extremities as slowly grow-ing solitary nodules. In our patient, the lesion was localizedon the leg which has a predilection for dermatofibroma.The common variant of DF is characterized by a well-circumscribed, red-brown nodule typically located on thelegs [2, 3]. In our patient, the lesion presented as around, dark-brown, black-colored nodule. The noduleshowed two nodular extensions to the periphery, develop-ing from the lesion toward the popliteal fossa. This was aunique feature as dermatofibromas with peripheral exten-sions and has not been previously reported to our knowl-edge. Sehgal et al. [7] reported a giant DF with satellitelesions around the dermatofibroma plaque. However, inour patient, these small nodules grew directly from theDF and gave an impression of an actively growing lesion,as seen in cutaneous malignancies and mainly nodularmelanoma. Rapid enlargement in the last 3 months andthe dark brown-black color of the lesion also stronglysupported this provisional diagnosis. As the lesion wasfound to be consistent with dermatofibroma, the periph-eral extension was considered to be a feature pointing tothe lesion’s evolution in this case.Figure 1. Dark brown-black nodule (1 9 1 cm) on the medial aspectof the leg.Figure 2. Nodular extensions toward popliteal fossa on close image(black arrows).Figure 3. Dermoscopic image with blue-red pigmentation areas on awhite structureless area (black arrows) and pinkish hue at theperiphery (blue arrow) surrounded by brown pigmentation.ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 1007E. M. Acar et al. Hemosiderotic dermatofibroma mimicking melanomaDFs can display a variety of dermoscopic patterns. Aperipheral delicate pigment network and central whitescar-like patch is the typical and most common dermo-scopic feature of DF [8]. Zaballos et al. [9] reported thatmost hemosiderotic and aneurysmal DFs showed multi-component pattern including a central bluish or reddishhomogenous areas and peripheral delicate network withvascular structures of variable degrees. Kilinc et al. [2]reported focal blue-gray pigmentation and a peripheralpinkish hue in two hemosiderotic DFs. We similarlyobserved, focal blue-red areas on a white structurelessarea and a focal pinkish red hue at the periphery, withblue pigmented areas most likely representing the prolif-eration of hemosiderin-containing macrophages in ourpatient.Hemosiderotic DF is considered as a precursor stage ofaneurysmal DF by some authors [6]. Aneurysmal DF canpresent with a blue-brown nodule that can rapidly growdue to extensive hemorrhage and therefore pose a diag-nostic challenge with melanocytic and vascular lesions. Inthe histopathological examination of our patient, Prussianblue demonstrated intracellular and extracellularhemosiderin deposition. Atypia, mitosis, or necrosis werenot present. HMB 45 and Melan A, which are markersfor melanoma, were negative. CD34 was positive; othermarkers such as S-100, SMA, cytokeratin AEI/AEI3, andFXIIIa stains were negative and were used to excludeother mesenchymal neoplasms.Dermatofibroma is generally known as a benign mes-enchymal neoplasm of the skin, but high cellularity,increased atypia, and proliferative activity can be seenhistopathologically especially in the cellular, aneurysmal,and atypical variants [1]. These variants may have anaggressive growth pattern and are more likely to metasta-size. In a study by Mentzel et al. [10] comprising sevencases of DF with recurrences and metastasis, chromoso-mal aberrations were detected in five patients by arraycomparative genomic hybridization (CGH). CGH may bea helpful technique in the recognition of DFs with malig-nant potential. Histopathological features such as highproliferative activity and increased atypia were notdetected in our patient, and we therefore did not performCGH or further examination despite the peripheralspreading of the nodule leading to a suspicion of a(A) (B)(C) (D)Figure 4. Histopathological examination (A, B): Interlacing fascicles of spindle cells in dermis with a storiform pattern, intracellular andextracellular hemosiderin deposits (H&E,X50; H&E,X100); (C, D): Positive histochemical staining of Prussian blue, showing hemosiderin deposits, inmost of the spindle-shaped cells (X100;X50).1008 ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd.Hemosiderotic dermatofibroma mimicking melanoma E. M. Acar et al.malignant lesion clinically. Simple excision is generallycurative for DFs, and the local recurrence rate is <2% [1].The lesion in our patient was excised with 5-mm margins,and no recurrence was seen after 1 year of follow-up.Hemosiderotic DF, which is a rare variant of der-matofibroma, has never been reported in children untilnow as far as we are aware. Our case was also interestingas the lesion clinically gave the impression of a rapidlygrowing melanoma with its dark brown-black color andperipheral spreading, but no features pointing to a malig-nancy were detected on histopathological examination,thus forming a clinicopathological discordance. The clini-cal appearance was attributed to the DF lesion’s evolutionwith the growth of the patient. It must be kept in mindthat DFs can enlarge with peripheric nodular extensionsin childhood, not necessarily pointing to a malignant pro-cess. Our case also reveals that hemosiderotic DFs mustbe considered in the differential diagnosis of pigmentednodular lesions in children.AcknowledgmentsWe would like to thank Senem SAS for technical assis-tance.Conflict of InterestThe authors declare that there is no conflict of interestregarding the publication of this article.AuthorshipEMA: involved in the acquisition of clinical andhistopathological data, design and draft of the manu-script, and revision and approval of the final manuscript;MT and AK: interpreted the histopathological data,designed and drafted the manuscript, and approved thefinal manuscript; FK: designed and drafted the manu-script, and approved the final manuscript.References1. Alves, J. V., D. M. Matos, H. F. Barreiros, andE. A. Bartolo. 2014. Variants of dermatofibroma-ahistopathological study. An. Bras. Dermatol. 89:472–477.2. Kilinc Karaarslan, I., G. Gencoglan, T. Akalin, andF. Ozdemir. 2007. Different dermoscopic faces ofdermatofibromas. J. Am. Acad. Dermatol. 57:401–406.3. Laureano, A., C. Fernandes, and J. Cardoso. 2015.Hemosiderotic dermatofibroma: clinical and dermoscopicpresentation mimicking melanoma. J. Dermatol. Case Rep.9:39–41.4. Black, J., C. M. Coffin, and L. P. Dehner. 2012.Fibrohistiocytic tumors and related neoplasms in childrenand adolescents. Pediatr. Dev. Pathol. 15(1 Suppl):181–210.5. Villarreal, D. J., A. T. Luz, A. M. Bucard, L. Abreu, andT. Cuzzi. 2017. Hemosiderotic dermatofibroma. An. Bras.Dermatol. 92:92–94.6. Scalvenzi, M., A. Balato, F. De Natale, M. G. Francia,C. Mignogna, and G. De Rosa. 2007. Hemosideroticdermatofibroma: report of one case. Dermatology 214:82–84.7. Sehgal, V. N., K. Sardana, S. Khandpur, S. Sharma,S. Majumdar, and A. K. Aggarwal. 2004. Giantcombined dermatofibroma with satellitosis. Clin. Exp.Dermatol. 29:147–149.8. Ferrari, A., G. Argenziano, P. Buccini, C. Cota, I. Sperduti,P. De Simone, et al. 2013. Typical and atypicaldermoscopic presentations of dermatofibroma. J. Eur.Acad. Dermatol. Venereol. 27:1375–1380.9. Zaballos, P., A. Llambrich, M. Ara, Z. Olazaran,J. Malvehy, and S. Puig. 2006. Dermoscopicfindings haemosiderotic and aneurysmal dermatofibroma:report of six patients. Br. J. Dermatol. 154:244–250.10. Mentzel, T., T. Wiesner, L. Cerroni, M. Hantschke,H. Kutzner, A. R€utten, et al. 2013.Malignant dermatofibroma: clinicopathological,immunohistochemical, and molecular analysis of sevencases. Mod. Pathol. 26:256–267.ª 2018 The Authors. Clinical Case Reports published by John Wiley & Sons Ltd. 1009E. M. Acar et al. Hemosiderotic dermatofibroma mimicking melanoma

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Hemosiderotic dermatofibroma mimicking melanoma in a 12-year-old boy: a case report

Acar, Emine Muge

Kırşehir Ahi Evran University Institutional Repository

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Hemosiderotic dermatofibroma mimicking melanoma in a 12-year-old boy: a case report

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